Cylinder sizing: less is more

MRI of common penile pathologies and penile prostheses

MRI can delineate finer details of penile anatomy and pathology due to inherent higher soft-tissue contrast and spatial resolution. It can characterize inflammation and identify abscesses, localize penile fractures, guide surgical planning in penile fibrosis and Peyronie's disease, and depict components of the penile prosthesis and its complications. MRI is a great investigative tool for penile neoplasms, including locally infiltrative neoplasms where clinical examination is limited, and local staging is crucial for surgical planning.

A prospective evaluation of penile measures and glans penis sensory changes after penile prosthetic surgery

Background

With better designed devices and lower infection rates, satisfaction with inflatable penile prosthesis (IPP) placement is increasingly high. However, dissatisfaction is still present and there is disagreement regarding length and sensation changes after the IPP placement. The aim of this study was to evaluate changes in penile length, girth and sensitivity after IPP placement.

Methods

From August 2012 to January 2013 all patients undergoing “de novo” IPP surgery were invited to participate in this study. Eighty six patients met inclusion criteria while 62 agreed to participate in this observational study. A week before surgery, penile length and circumference, and glans/elbow biothesiometer readings were recorded 15 minutes after Trimix induced erection. Same measures were taken at postoperative week 6 and month 6.

Results

Amperage from Glans biothesiometer readings showed statistically significant shorter readings than elbow biothesiometer preoperatively, 6 weeks and 6 months after surgery (P<0.001 each). No significant sensory difference in the glans penis after IPP was noted. However, compared to preoperative Trimix induced erections, penile length and circumference were greater after IPP placement (P=0.04 and P=0.001, respectively).

Conclusions

We observed statistically significant increase in penile length and girth after IPP placement without significant changes in sensory conduction.

Implantation of AMS 700 LGX penile prosthesis preserves penile length without the need for penile lengthening procedures

Implantation of an inflatable penile prosthesis (IPP) is a well-established definitive solution for erectile dysfunction when conservative treatments fail. Penile implants may shorten the penis. The AMS 700 LGX IPP is in common use but reports on its mechanical reliability, medium-term postsurgical patient satisfaction, and mean penile length preservation are lacking. We investigate the mean penile length, mechanical reliability, and patient satisfaction at 6 and 12 months after implantation of the AMS 700 LGX. This prospective study consecutively enrolled men undergoing first-time IPP implant surgery from February 2009 to April 2012. Stretched flaccid penile length, penile length at 50% and 100% of stiffness (P50 and P100) and International Index of Erectile Function (IIEF) and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) scores, were measured at 6 and 12 months postsurgery. Of 45 patients who underwent AMS 700 LGX implantation (median age 61 years) and completed 6 months’ follow-up, 36 (80%) completed the study. A significant difference in stretched flaccid penile length was seen between 6 and 12 months (P = 0.033). P100 was also significantly increased at 6 and 12 months, with a mean 10% increase (1.3 ± 0.4 cm) from baseline to 12 months. Differences in mean IIEF scores at 6 and 12 months were significant for the desired domain (P = 0.0001) and for overall satisfaction (P = 0.002); however, mean EDITS scores at 6 and 12 months were not significantly improved. AMS 700 LGX is a powerful tool for preserving penile length in men undergoing penile prosthesis implantation.

Penile prosthesis implantation in the era of medical treatment for erectile dysfunction

Penile prosthesis implantation, the oldest of the modern treatments for erectile dysfunction (ED), still plays an important role despite the advent of less invasive alternatives. For some men with ED, penile prosthesis implantation is the only effective or acceptable treatment. Penile prosthesis implantation remains a viable option in the contemporary management of ED as evidenced by annual penile prosthesis implantation cases in the United States rising from 17,540 in 2000 to 22,420 in 2009. Improvements in prosthesis design and implantation techniques have resulted in significant increases in device survival and patient satisfaction.

Comparison of a new length measurement technique for inflatable penile prosthesis implantation to standard techniques: outcomes and patient satisfaction

INTRODUCTION

Within a study evaluating the redesigned AMS 700MS inflatable penile prosthesis (IPP) (American Medical Systems, Minnetonka, MN, USA), one site used new length measurement technique (NLMT), a more aggressive dilation and measurement of the corpora cavernosa on a stretched penis, to address penile shortening.

AIM

To compare cylinder size and patient satisfaction, between a NLMT and traditional sizing for IPP implantation.

METHODS

Fourteen men received IPPs using NLMT, and 55 with traditional sizing. Nationwide sales data from 2005 to 2008 for AMS 700 IPPs was obtained from AMS for comparison; additional surveys captured patient satisfaction.

MAIN OUTCOME MEASURE

Demographic data, cylinder sizes, and patient satisfaction were compared between the NLMT and standard techniques.

RESULTS

The Fisher's exact test (P<0.001) showed a significant difference between the cylinder sizes with NLMT as compared with standard techniques. Of the 14 NLMT patients, 71.4% (10) received cylinders>21 cm long and 28.6% (4) received cylinders<21 cm long, as compared with 12.7% (7) and 87.3% (48), respectively, for patients implanted by traditional techniques. There were ethnic differences between the samples: 42.9% (6) NLMT patients were of African-American descent, as compared with 10.9% (6) in the standard technique group. However, longer cylinders were utilized more often, with 83.3% (5) of African-Americans treated using the NLMT; as compared with 33.3% (2) of the standard technique group. Nationwide data reveal 12.3% of patients routinely receive 21 cm cylinders. At 6 months postimplantation, patient satisfaction with NLMT was no different than standard techniques. There were no distal erosions, complications, infections, or pain concerns reported through 24 months among the NLMT patients.

CONCLUSIONS

The NLMT resulted in a larger number of subjects implanted with larger cylinders. Satisfaction with performance and complication rates for NLMT patients was comparable to those implanted using standard techniques.

[A cylinder aneurysm of a penile prosthesis]

Herniation of a penile prosthesis (cylinder aneurysm) is an extremely rare complication of penile prosthesis surgery. We report the first case of such an aneurysm in a patient with spinal cord injury. The treatment of choice is surgical revision with replacement of the faulty device. Filling of the implanted system with contrast media facilitates preoperative diagnostic workup.

Increasing size with penile implants

Penile prosthesis implantation is suitable treatment for men with erectile dysfunction when nonsurgical treatment options fail or are otherwise unsatisfactory. Three-piece inflatable penile prostheses closely approach the ideal of producing normal penile flaccidity and erection. Nevertheless, even in men with normal corpora cavernosa, many report their prosthetic erection is shorter than their former natural erection. This is due to the lack of glans tumescence and the use of penile cylinders, which only expand in girth. Using girth- and length-expanding cylinders can decrease the loss of penile length frequently seen with prosthesis implantation. Some penile prosthesis recipients have abnormal corpora following radical prostatectomy or after removal of an infected penile prosthesis, or as the result of Peyronie's disease, obesity, or ischemic priapism. In these men with abnormal corpora, associated penile-lengthening procedures can be combined with penile prosthesis implantation. However, experience is limited with these combined procedures.

Penile length alterations following penile prosthesis surgery

OBJECTIVE

Determine the impact of penile prosthetic surgery on penile length.

METHODS

Stretched flaccid penile length was measured in men undergoing first-time penile implant surgery. Measurements were done before implantation and at 1 and 6 mo postoperatively. Patients were evaluated by the International Index of Erectile Function (IIEF) preoperatively and the IIEF and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) at 6 mo postoperatively. Patients also provided subjective assessment of penile changes at 6 mo postoperatively. Preoperative and postoperative IIEF and EDITS scores were compared as were the patients who complained of penile length loss with those who did not.

RESULTS

Of the 56 patients, 50% were diabetic and 28.5% had previous radical prostatectomy; 78% of the implants were three-piece (Alpha-1, Mentor) and 22% were two-piece (Ambicor, American Medical Service). There were no statistically significant differences in penile length after the surgery compared to preoperative measurements. Forty of 56 patients (72%) reported a decrease in penile length, 10 of 50 (19%) reported no change, and 6 of 56 (9%) had a slight increase. Subjective penile length loss was more common in patients who had undergone radical prostatectomy before prosthesis implantation (32%). No statistical difference in EF domain scores occurred between patients who complained of penile length loss and those who did not; however, men complaining of length loss had lower IIEF satisfaction domain and EDITS scores.

CONCLUSION

Penile prostheses do not have a negative impact on measured stretched flaccid penile length. Treatment satisfaction scores do not depend on subjective penile length loss.

Current role of penile implants for erectile dysfunction

PURPOSE OF REVIEW

The purpose of this review is to appraise new developments and publications in the field of penile prosthetic surgery. Urologists dealing with erectile dysfunction need to recognize the value of penile prosthetic surgery as a very efficacious treatment for this common condition. This type of surgery is needed in a considerable proportion of patients with erectile dysfunction so this review is timely and relevant.

RECENT FINDINGS

The main themes in the literature covered include risk factors for infection of penile prostheses, its prevention with the use of hydrophilic and antibiotic-coated prostheses, particularly in re-operations, and its management with the new rescue procedures. Surgical tips for prosthetic surgery are also reviewed as well as clinical outcomes and factors influencing them.

SUMMARY

Of all the invasive treatments currently available, placement of a penile prosthesis is one of the most successful, giving high levels of satisfaction. With the aid of new technical advances, the risk of infection--the most feared complication--can be minimized so prosthetic surgery may play a major role in the treatment of erectile dysfunction.